Thursday, February 15, 2018

Last Saturday, the National Keratoconus Foundation hosted its 2018 Keratoconus Family Symposium at UC Irvine. I had the pleasure of attending and even the privilege of speaking at it.

A bit of background for dry eye readers

For those who have never heard of it: keratoconus is a rare corneal disease affecting at least 1 in 2,000 people (though one of the speakers at the event voiced his opinion that it's actually much more common but frequently goes undiagnosed). I'll borrow directly from the NKFC website for a definition:

Keratoconus, often abbreviated to “KC”,

is a non-inflammatory eye condition in which the normally round dome-shaped cornea progressively thins causing a cone-like bulge to develop. This results in significant visual impairment.

This is obviously not a Dry Eye Thing, so a brief word about how and why I got involved is probably in order. Of course, many keratoconus patients have dry eye, so I have known many over the years just in the normal course of Dry Eye Company 'business' whether through blogging, emails and conversations, or actual retail.

But the closer connection for me with keratoconus patients is through scleral lenses, which are commonly used for correcting the vision impairments keratoconus can cause. (I too have vision not correctible with other types of lenses though for different reasons.) Actually, I first came across keratoconus way back in 2002 or so when I was doing advocacy work for people with complications from LASIK, because there is a medically induced version of keratoconus which we tended to refer to as post LASIK corneal ectasia. These days, because the Dry Eye Shop has expanded more and more into scleral lens supplies, questions that flow in through the shop are the main way I keep up a lot of communication with keratoconus patients, as well as our Facebook group, My Big Fat Scleral Lens, and it's through scleral lenses that I came to know the current director of NKFC, Mary Prudden, who was responsible for organizing this excellent event.

So, on to the actual contents of the day:

Gloria Chiu OD (USC-Roski Eye) provided an excellent framework for the presentations of the day by giving an introduction to keratoconus with an overview of its causes, onset, and progression as well as the treatments, which are pretty much limited to specialty contacts and corneal transplants, though corneal crosslinking is now being used as a preventive treatment for younger cases. If I'm not mistaken, Dr. Chiu is the only PROSE fitter west of the Mississippi. It was a joy to meet her for the first time as I've known a great many of her patients over the years.

Mindy Hutchinson MD (Vita Behavioral Health, PA) talked about the mental health impact of eye disorders. She was diagnosed at the age of 26 with keratoconus, of which she had never heard during medical school. She walked us through her own path and discussed anxiety, depression, learned helplessness and what it looks like to take back control, including education, accommodation, advocacy, and self-care.

Vivian Shibayama OD (UCLA-Jules Stein) presented on contact lens options for different stages of keratoconus, including: soft torics; corneal RGPs; topography guided RGP designs; piggybacking; hybrid lenses; and finally sclerals. She addressed some practical questions such as about refilling lenses during the day. In a second presentation, she covered scleral lenses in more detail including multifocal optics, EyePrintPro molded lenses, Hydra PEG coating, and various questions relating to solutions for both soft and rigid lenses.

Incidentally, I was curious about the current status of piggybacking - that's something I tried back around 2003 but was not able to tolerate the soft lenses. I wondered whether scleral lenses have made piggybacking obsolete but clearly they haven't - the cost and commitment factors in sclerals are such that the simpler, more cost-effective approach of piggybacking is better for some users who are still able to tolerate lenses on the cornea.

Yours truly presented on practical pointers for scleral lens users including those with dry eye, but you've heard so much from me I won't regurgitate it here!

Marjan Farid MD (UC-Irvine/Gavin Herbert) presented on corneal transplantation techniques. She discussed some current challenges such as rapid visual recovery, astigmatism management and getting patients out of contacts, and improvements in targeting different procedures to specific diseases. Femtosecond laser technology is bringing great improvements due to precisely targeted cuts and she presented on this area in great detail, particularly the zigzag method, including videos of DALK employing femtosecond zigzag cuts on the donor cornea and the receiving cornea. Questions she addressed included: "Does crosslinking ever lead to transplants?" (hopefully infrequently), "Can you get KC after the transplant?" (transplant is only 8-9mm so there is less risk of ectasia), and "How often are sclerals still required after transplant" (fit is better after, so "a lot" don't need sclerals).

Sam Garg MD (UC-Irvine, Gavin Herbert) presented on the hottest topic of the day: corneal cross-linking (CXL), which was finally FDA approved just over a year ago after having been used in Europe for many years. He started with some broader keratoconus background including risk factors (incl. Down syndrome, genetics, eye rubbing, connective tissue disorders) and also mentioned - new to me! - that the cornea is the driest tissue in the body! He explained that, like so many medical interventions, we don't know how crosslinking works, we only know that it seems to be effective at stiffening the cornea. He presented a great deal of technical background on the treatment and how it is employed. It is only approved for patients 14 years old and older. Candidates are those with keratoconus or post LASIK ectasia that is demonstrated to be progressive (though he said that with the younger ages they do not necessarily bother documenting progression first as it can be assumed to be progressive in young patients). He discussed what the procedure and healing period are like and mentioned potential complications such as haze and sterile infiltrates. There is debate about "epi-on vs. epi-off", that is, whether to perform it with or without the corneal epithelium in place. Dr. Garg addressed many audience questions, including: "When does KC historically stabilize?" (it's a spectrum), "How soon is a CXL patient able to wear contacts" (2-3 months or more), "Can it be done on younger than age 14" (off-label, yes), "Will there be any insurance coverage" (Avedro is pushing hard for this), "How much does it cost" ($5-6k with current riboflavin costs), and "How and when is patient satisfaction measured" (this question from yours truly and the answer is that there has been no formal measure of it).

Elio Spinello PhD (CSUN-Northridge) presented on various pitfalls of medical information on the internet, focusing on a variety of tests and red flags to look for when trying to determine the reliability of a given source. He emphasized the importance of having medical providers you trust and presented data on the role this plays in the extent to which people rely on what they read.

Wendy Pawling (UC-Irvine voc. rehab consultant) presented on accommodations in the workplace as well as school environments. She discussed relevant Federal and California disability laws with the aim of informing and equipping people with visual disabilities (assuming they are able to perform their essential job functions) to be able to request accommodations and to know what to expect and what an employer is, and is not, obliged to do. She discussed the interactive nature of the process and privacy limitations; for example, employers are not allowed to ask you your diagnosis, nor can they contact your doctor(s). She gave examples of accommodations she's familiar with at UCI, from equipment or software to modified work schedules.

Rachel Dungan MSSP (NKCF patient advocate) wrapped up the presentations with a powerful, moving talk including her personal story. She shared how keratoconus progressively and profoundly impacted her education and professional trajectory as well as her mental wellbeing for some years before she was diagnosed, and the many ways in which the experience as a whole has changed her. She discussed what patient advocacy and patient empowerment look like, how patients can educate themselves as well as those close to them about their needs both in visual health and emotional health. She described hopeful signs that patient-centered care is being increasingly valued.

The presentations were followed by a tour of the Eye Bank at Gavin Herbert Eye Institute as well as workshops on stress management, advocacy and scleral lens and dry eye troubleshooting. Somewhere in there we also had lunch. Aidan (assistant, who accompanied me to the event) and I sat with a family whose 17 year old son was recently diagnosed. The conversations with the parents were probably the most impactful part of the education I received that day, as they told what it's really like trying to help a young person at such an intensely vulnerable time of life come to grips with having a rare eye disease, as well as the many practical and financial considerations impacting their whole family.

Many thanks to Mary Prudder and NKCF for this wonderful event! I learned so much, and met a lot of wonderful people. It was a great day. - Also, thank you to Aidan for taking great notes for me so that I could just sit back and listen and absorb.

Thursday, January 25, 2018

A study by Hank Perry et al (OCLI) was published in Cornea last year showing that dry eye patients who sleep on their side or face down have more dry eye than those who sleep on their backs:

A statistically significant difference was shown with back sleeping compared with left side sleeping using lissamine green staining (analysis of variance, P = 0.005). The Ocular Surface Disease Index score was also found to be elevated in patients who slept on their right or left side (36.4 and 34.1, respectively) as opposed to back sleepers (26.7) with P < 0.05.

That was not nearly so startling as Dr Perry's comments about MGD in an article in this month's EyeWorld, because while the study results specifically stated that there was no statistically significant correlation between sleep position and degree of MGD, Dr Perry and colleagues clearly feel sleep position really does matter to the meibomian glands. For example:

The authors theorized that the problem is a mechanical one. The glands are fairly delicate and they function perfectly when there is nothing compressing them, but if you compress the glands, you have a direct effect on their ability to function, and this in turn leads to increased inflammation in the glands with eventual dropout and increasing severity of meibomian gland dysfunction.

Quite a theory.

This is a topic of keen interest to me. At the Dry Eye Shop we work daily to try to help people find dry eye products - not just gels and ointments but goggles, masks, shields, patches and tapes - that can increase the moisture in their eyes overnight without disrupting their sleep patterns. Their choice of products in many cases is limited by their sleep style - for reasons of safety as much as comfort.

Many people, for example, come to us after a doctor's referral and ask for a mask or goggle that will hold their lids down. This always concerns me, for reasons such as:

If the lids aren't fully closing, what will happen if the mask slips? They might be at risk of a corneal abrasion.

If they sleep on their side or stomach, won't it press on their eyes and give them blurry vision in the morning, or worse?

If they adjust the mask or goggle too tightly, might it not press dangerously on their eyes, even if they sleep on their back?

Et cetera.

So, in my personal recommendations, I have found myself trending more and more towards encouraging people to employ tools that will, without pressing on or even touching their eyelids, block air movement and hold moisture over their eyes.

bubble type bandages like NITEYE and Ortolux, which are stiff enough to hold up to some pressure and keep anything from touching the eyes;

post surgical shields such as the LASIK goggle, in extreme cases such as patients with floppy eyelid syndrome, where they must have secure, rigid protection to prevent literally rubbing the eyes (and corneas) on the bedding, or unconsciously rubbing the eyes with their hands during sleep.

In the cases where their doctor insists the lids be held shut, I encourage them to use skin-friendly silicone medical tapes or EyeLocc strips as opposed to masks or Tranquileyes. (To be clear - I think that if you're willing to put in the extra work to customize thickness of the Tranquileyes pads to get a very light pressure, it can work quite well for back sleepers - yet the safety factors remain a concern because they're so patient-specific.)

Then of course there are a host of special cases. Fibromyalgia, multiple chemical sensitivities and innumerable others introduce complicating factors that make the night solutions require ever more creativity. Nevertheless, it can be done!

But to return to the point of the study and the news report in EyeWorld: Is it really possible that physical compression of the meibomian glands from your sleep style could have a direct knock-on effect on your meibomian glands?I eagerly await solid medical studies to answer this question.

Background: We aimed to investigate the clinical importance of conjunctivochalasis (CCH) and, further, to implement a new CCH classification system.

Methods: 60 eyes of patients with whom, upon clinical examination, CCH was diagnosed were investigated for the presence of symptoms and signs characteristic of dry eye. The eyes were grouped based on two stages of severity, Stage 1 (minimal/mild) and Stage 2 (medium/severe), for each nasal, middle, and temporal position, and on the extent of CCH folds in each site.

Results: In 40 (66.6%) out of 60 eyes, symptoms and signs of CCH were manifest: pain in 25 (41.6%), epiphora in 25 (41.6%), and lacrimal punctum obstruction from conjunctival folds in 22 (36.6%) eyes. Depending on the position of CCH, a greater percentage of symptoms appeared in Stage 2 in the nasal position (78.9%), followed by middle (68.7%) and temporal positions (60%). When TBUT values were compared, statistically significant differences were found proportional to grading (p < 0.001) and position (nasal more severe than temporal, p < 0.001), and such differences were also found when TBUT values of all eyes were compared with those of symptomatic eyes (p = 0.01) and with those of symptom-free eyes (p = 0.002).

Conclusions: CCH is a rather frequent and commonly unrecognized condition that should always be considered in differential diagnoses of dry eye.

1. Randomised masked trial of the clinical safety and tolerability of MGO Manuka Honey eye cream for the management of blepharitis.

Abstract

OBJECTIVE:
To assess the clinical safety and tolerability of a novel MGO Manuka Honey microemulsion (MHME) eye cream for the management of blepharitis in human subjects.

METHODS AND ANALYSIS:
Twenty-five healthy subjects were enrolled in a prospective, randomised, paired-eye, investigator-masked trial. The MHME eye cream (Manuka Health New Zealand) was applied to the closed eyelids of one eye (randomised) overnight for 2 weeks. LogMAR visual acuity, eyelid irritation symptoms, ocular surface characteristics and tear film parameters were assessed at baseline, day 7 and day 14. Expression of markers of ocular surface inflammation (matrix metalloproteinase-9 and interleukin-6) and goblet cell function (MUC5AC) were quantified using impression cytology at baseline and day 14.

RESULTS:
There were no significant changes in visual acuity, eyelid irritation symptoms, ocular surface characteristics, tear film parameters and inflammatory marker expression during the 2-week treatment period in treated and control eyes (all p>0.05), and measurements did not differ significantly between eyes (all p>0.05). No major adverse events were reported. Two subjects experienced transient ocular stinging, presumably due to migration of the product into the eye, which resolved following aqueous irrigation.

CONCLUSION:The MHME eye cream application was found to be well tolerated in healthy human subjects and was not associated with changes in visual acuity, ocular surface characteristics, tear film parameters, expression of markers of inflammation or goblet cell function. The findings support future clinical efficacy trials in patients with blepharitis.

METHODS AND ANALYSIS:In vitro phase: Bacterial growth inhibition was assessed by area under the growth curve (AUC) for Staphylococcus aureus, and the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) for S. aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa with cyclodextrin-complexed and uncomplexed Manuka honey were determined. In vivo phase: Six rabbits were administered 20 µL of MHME (at 1:10 dilution) to the right eye (treated) and 20 µL of saline to the left eye (control) daily, for 5 days. Tear evaporation, production, osmolarity, lipid layer, conjunctival hyperaemia and fluorescein staining were assessed daily, before and 15 min after instillation.

Prevalence of dry eye disease and its association with dyslipidemia.

BACKGROUND:Dry eye disease (DED) is a common ocular surface disease significantly affecting the quality of life of patients. The aim of our study is to focus on the prevalence of DED and to determine the relationship between dyslipidemia and DED.METHODS:The study was performed with the age group of 25-70 years, who attended the ophthalmology outpatient department at Sri Lakshmi Narayana Institute of Medical Sciences with complaints of dry eye. A standard questionnaire was taken, and tear film tests were performed to diagnose dry eye. Further eyelid margin was examined to detect meibomian gland dysfunction. Based on the tests and examination, patients were grouped as men with and without DED and women with and without DED. Fasting lipid profile was investigated for these groups.RESULTS:The study showed the prevalence of DED mainly in women and found significant association between DED and dyslipidemia. There is a significant relationship between total cholesterol and DED groups especially in women (p<0 .001="" also="" and="" as="" association="" between="" br="" cholesterol="" compared="" ded="" density="" found="" high="" in="" lipoprotein="" low="" men.="" particularly="" the="" to="" triglycerides="" we="" women="">CONCLUSION:Based on the findings, we emphasize that there is a strong relationship between dyslipidemia and the progression of DED particularly in women. Ophthalmologists may increase their role to educate themselves to diagnose dyslipidemia and ensure comprehensive eye care to prevent blindness and cardiovascular disease. Recent treatment modalities could be aimed to improve the quality of life of women and elderly patients suffering from DED.0>

For those of you with larger orbits who have found this product too small - especially too short top to bottom - I'm very pleased to say that the manufacturer is working with us on a larger version and I received some samples of it last Friday... It's not much longer but it's a fair amount taller (i.e. from top of lid to cheek) and gets taller sooner rather than a slow taper. I think this one will fit, not everyone, but most of the people who found the original too small. We're still pondering what the best size will be as a one-size-fits-all. We have a few samples of these larger ones in anyone wants to try them.

Saturday, November 11, 2017

Packed day. I have never seen so many ophthalmologists in one place. I used to go to the ASCRS meetings, and sometimes ARVO... but this is... bigger.

Some highlights:

Exhibit hall...

At the big ophthalmology meetings these are dominated by top dollar technologies, so not a huge lot there of interest to our dry eye world, but here are notes from a few of my visits:

Lipiflow presentation (in the Johnson & Johnson family now).

Audience question: "Does it still work when most glands are truncated?" Answer: "Yes.... It's mostly about preserving glands that are functional - that's the way to present it to patients."

One presenter said she has always done a thorough cleansing with Ocusoft on a sponge immediately before Lipiflow, and patients seemed to do better that way, but is now considering switching to Blephex.

Audience question: "If the patient is needing both Lipiflow and cataract surgery, how far in advance of surgery should Lipiflow be done?" Answer: "Give it plenty of time. Usually you see a huge difference in the topography in a month."

Allergan: Among the enormous team they had there I hunted down someone who could talk to me about Refresh PM. He was confident it is coming back quite soon - had heard two weeks ago that it would be about a month.

Alcon: I was NOT able to hunt down anyone who knew anything about when Bion Tears will be back. ("Is that an Alcon product? Really?") I have since learned that this has yet again been rebranded as Genteal Tears (pf version) so apparently Alcon's site, not to mention staff, just haven't quite caught up with this.

Ocusoft: Had a gander at their latest stuff which I'd been meaning to catch up with. Basically knockoffs of Avenova (Hypochlor) and Refresh Optive (Retaine Tears). Going to add these to the DryEyeShop.

Nanotears (Altaire). Breezed by and looked at ingredients - looks like basically a Systane family knockoff. I have my own history with Altaire so I didn't stay to chat.

Rendia - patient education videos, etc. Had a good chat with these folks, will consider whether getting access to their videos for DEZ would be a good idea, also considering what it would look like to collaborate with an outfit like this on making educational videos on more topics of interest to the severe dry eye and the scleral lens crowds.

Meeting with Shire...

In September 2016 I met someone who worked in patient advocacy at Shire, at the TFOS conference in Montpellier. We connected later in the year about some projects to explore, but we eventually lost touch and he has moved on from that group. So today I met with someone new to that group who is a true veteran of the patient-advocacy-within-the-pharmaceutical world, and it was a pleasure. This is not someone from the marketing side trying to play nice with patients. This is someone whose professional focus is all about increasing patient access to treatment, via all sorts of channels including education about insurance, and about legislative activism and so on. Anyway, enjoyed the meeting, kicked around some possibilities and will keep in touch.

Cornea Subspecialty Day...

I did not bother with the three morning sessions, which weren't in core areas of interest for me (corneal infections, keratoplasty, and conjunctival tumors). But the afternoon held a lot more of interest.

Section IV - Anterior Segment Imaging

Attended this more out of personal interest than anything related to dry eye - dates back rather to my early advocacy days for LASIK complications folks.

Dr Majmudar on aberrometry... I love people who take aberrometry seriously. (And I can't help loving the term "abberropia" which so aptly describes post LASIK vision for some of us.) Fun to hear about great ways they're using it for more informed diagnosis and surgical planning in non elective procedures.

Dr Shousha (Bascom Palmer, another of my favorite places) and later Frank Price on intraoperative OCT - a real time cross section of the cornea... loved it.... helping prevent descemets perforation during keratoplasty or more accurately diagnose complications post operatively.

Section V: Keratoconus

Learned lots about diagnosis, and especially early diagnosis of Keratoconus... wasn't really a huge area of interest until the last couple of years and the "Great Saline Crisis" when I suddenly made the acquaintance of vast hordes of keratoconics and got curious about how it works. Dr Michael Belin was really adamant about the importance of diagnosing subclinical keratoconus and treating early to avoid vision loss. Dr Debbie Jacobs, one of my favorite people (medical direction at BostonSight) presented on the full range of specialty contact lenses from piggybacking to PROSE. There was a presentation on corneal crosslinking by a colleage of Dr Glassner's who wasn't able to make it.

The most remarkable thing to me from this entire section was that everyone gets very excited about surgery, and almost no one considers contacts/sclerals/PROSE. Dr Jacobs presentation was excellent and yet felt like a blip in an ocean of cutters. Hmmmm. I probably wouldn't be raising the point if it weren't that so many scleral lens and PROSE users that I know have had corneal grafts or other very invasive surgeries - and still needed the lenses afterwards - which makes one wonder if (in situations where it might have been appropriate) they were offered that option before surgery.

Section VI: Inflammatory Conditions of the Anterior Segment

This was the only cornea session really touching much on our pet topics here related to dry eye.

Dr Anat Galor (Bascom Palmer) presented on the many dry eye diagnostic tests available now (differentiating between those that spit out numbers and those that are qualitative only). She also mentioned a Sjogrens-specific test available from B&L, but the patient cost was quite high ($614).

I'm looking up my notes on the allergic conjunctivitis presentation and reflecting on the fact that I have been sneezing nonstop today, despite the pollen.com report being low for New Orleans today. But I REALLY enjoyed this presentation by Dr Deepinder Dhaliwal (UPMC). Technical information but a lot of common sense practical stuff that people ignore - like, don't rub your friggin' eyes! and that if itching is present, allergy is very likely. And to wash all your bedding in hot water. Wash your hands and change your clothes when you get home, when the pollen count's high. Went over treatment regimens, all the usual stuff but she also mentioned a sublingual immunotherapy which is apparently effective for ocular allergy? I must look this one up.

Dr Wuqaas Munir on Stevens Johnson Syndrome - I really appreciated getting a better understanding of how this disease works and what happens when it's chronic. Only surprised to not hear more about PROSE as a treatment.

Dr Steve Pflugfelder (Baylor; world known dry eye specialist incidentally) - breath of fresh air to hear PROSE mentioned casually in every context where it OUGHT to come up, as though he assumes everyone is already up to speed on that. Anyway his talk was on Sjogrens. One of the things that clicked with me was the intense environmental vulnerability of the Sjogrens eyes. He mentioned a study - it went by too fast and I haven't found it yet - where just 90 minutes' exposure to a bad environment for eyes (eg very low humidity) was enough to cause measurable clinical change. - Later on during Q&A I was interested to hear him sum up hormone based treatments as all very interesting but... little evidence of actual efficacy. Oh and one last highlight, someone asked about preservative free steroids, and again, he managed to make it sound like this should be NORMAL (thank you Dr P).

Last, there was a great little presentation by Dr Chris Rapuano (Wills Eye), wish he hadn't disappeared so quickly afterwards so I could have thanked him, on SLK, which he described as constantly getting missed in diagnosis. "Lift the lid and make them look down!". Often occurs alongside dry eye and/or bleph. More common among middle ged females. Associated with thyroid disease. Lots of superior staining and a 'velvety' pattern.

After that it was all about waiting for uber and finding really good gumbo. Tomorrow is another day!

Wednesday, November 8, 2017

Ointments, ointment, ointments... one of those necessary evils for so many people!

I've been hearing from a lot of people who are concerned at not being able to find Refresh PM, or at least not for an accessible price.

Yes, Refresh PM as well as Refresh Lacri-Lube are on backorder at the manufacturer and have been for some months now, so the wholesalers are running out and many retailers are completely out.

Yes, the Amazon and eBay scalpers are out in force as usual.

Lacri-Lube is easier to find than Refresh PM.

No, so far as I know, neither product is being discontinued. I've learned the hard way not to be too adamant when I say that! Because, you know, that's what I said the first couple of times someone asked me if Unisol 4 was being discontinued, back in mid 2015. ("Of course not!" followed by a quick call to the manufacturer and then.... um... "Oh dear. I can't believe it but...") One never knows for sure, because of course, while we've been talking to Allergan frequently about this, if the product really were being discontinued, from past experience it seems likely that their sales staff might be the last ones to learn.

At any rate, I am ever so cautiously optimistic, emphasis on the optimistic, that Refresh PM and LacriLube are merely backordered, NOT on their way out.

Meantime, there ARE other ointments available, like Genteal Ointment and Systane Ointment. The only unique thing about Refresh PM is the proportion of petrolatum to mineral oil (57.3%:42.5%, versus 94%:3% in the Alcon ones). For many people, these details don't matter; for some, they do matter. (You know who you are.)

If you're not able to get Refresh PM at a reasonable price right now, my suggestions would be:

The overall objectives of this survey are to set priorities for new research related to management of dry eye and to identify outcomes that patients consider important. We have already surveyed doctors who manage patients with dry eye. Now, to find out what is important to patients, we are surveying patients with dry eye, like yourself.

Password = dryeye

We anticipate this survey may take you up to 30 minutes to complete. Please complete this survey by Tuesday November 21, 2017.

We greatly value your participation and thank you in advance for being part of this important research!

Tuesday, July 25, 2017

In this Dry Eye Awareness Month series of posts, I've been trying to avoid re-hashing well known or readily available information, focusing instead on the patient-friendly angles that just don't get covered. But in practical things like night protection, I find that the 'information spread' is so large that I don't want to make assumptions... what's old hat to many patients is completely unknown to many others who could benefit. So, for night dry eye, I'm going to start by framing it with some key principles.

Fundamentals of night management

Eyelid care: For bleph/MGD sufferers, warm compresses and lid hygiene just before bed can help with better nights.

Environmental issues: Ceiling fans, heat and A/C are lethal. If they can't be avoided altogether due to factors like climate and partner preferences, then they have to be compensated for aggressively with other forms of physical protection. Finally, in low humidity climates, a humidifier may be necessary, but don't use one unless you're prepared to keep it clean.

Lubrication: Do you have a good enough lubricant that is lasting long enough?

Physical barrier protection is KEY! Most people with severe symptoms benefit from some type of mask, shield, goggle, patch, or other physical protection at night. This is especially critical if their lids don't fully seal during sleep, but it is definitely not only people with poor lid closure that benefit.

Goop?

Circling back to an ancient debate about whether ointments are good or bad. Personally, I don't particularly care about the principle of the thing all that much anymore. Seems to me that what works, works, and what doesn't, doesn't. I mean, in theory, I think ointments (i.e. petrolatum and mineral oil in varying proportions, depending which brand of a product with "PM" in its name you choose) are acknowledged by many to be not the greatest idea, in that grease effectively prevents liquid, in this case tears, from reaching the surface it's slathered on, so the eyes don't get the nourishment they need and deserve. But in real life, it's all about what actually works for real people. I have known so many people for so long who always do best with ointment at night. On the other hand, there are those whose eyes do get worse over time when they use ointment nightly, but who may have simply assumed it was disease progression and never questioned whether something they're using might actually be irritating their eyes in some way.

Physical barrier protection

At my DryEyeShop business, a great deal of our phone time is spent in what we call 'night consultations': troubleshooting how best to help someone protect their eyes at night.

It's really quite a challenge at times to find tools that will accommodate all the different types of constraints that may be in play, and address them well enough for someone to be able to live with it every night. Consider the following variables:

Sleep style (back, side, stomach)

Material sensitivities (latex, silicone, plastics, foams)

Tolerance for things touching the lids while sleeping

Skin type and conditions (edema, easily impressible, sensitive)

Size and fit issues (large hat size, large orbits, very small head, eyes close together, extremely long lashes, very prominent eyes, very deep set eyes)

Eyelid conditions (damage, scarring, missing parts of lids)

CPAP usage (full face, nasal pillow, strap configurations)

Non-closing eyelids (abrasion risk depending on sleep style? Do we force the lids down or simply vault them and keep the eyes safely sealed in?)

General safety (ensuring patient can see to prevent falls during the night)

Corneal safety (patient rubbing hands in eyes, or eyes on pillow during sleep? How to balance comfort with keeping something securely in place?)

Costs (is there a home-made version? A lower-cost alternative? How often does it have to be replaced? Are there parts that have to be replaced periodically?)

Maintenance (does it involve too many steps for someone with severe arthritis? Too delicate for someone with Parkinsons?)

Et cetera....

WOW. That's actually the first time I have done a rapid-fire stream-of-consciousness list on that topic, and it turned out even longer than I expected it to! It's not exhaustive, either — every single case is different. I could spend weeks writing up all different types of situations we've encountered and tried to find solutions for over the years. I can't address them all in the blog here, but I will tackle a few of the broader issues that come up frequently.

Incidentally, while I don't want to use the blog to push people to my shop, I do want to mention that consulting on these things is always free, and encompasses not just what we sell, but everything we know is available, so feel free to call to brainstorm solutions! We're at 877-693-7939.

What to do when your lids don't close

This is probably the single most common issue that comes up: People whose eyelids don't close need protection to ensure the corneal surface doesn't dry out. Situations range from relatively mild — where one naturally has a small opening between the lids during sleep (not normally a big problem until/unless you also have dry eye!) — to botched blepharoplasties where there might be a slightly wider opening — to wide openings due to facial palsies, damage to eyelid muscles, injuries and so on.

So the first and most basic decision is this:

Do I attempt to force the lids to close?

It has been my experience that if there is any way you can avoid forcing the lids closed, you should — for the very simple reason that forcing the lids down will usually make it harder to sleep, especially in severe cases. There just aren't all that many ways to force the lids down that are comfortable enough to endure all night.

There are lots of exceptions, and one of the most prominent of the exceptions is people who also have recurrent corneal erosions, where immobilizing the eyelids can be very helpful by preventing the sudden eyelid movements that so often precipitate erosions. People with extremely severe aqueous deficient dry eye plus exposure from poor lid closure sometimes also find nothing will protect them adequately short of taping them down.

...Or do I use a sealed moisture chamber?

The idea here is to seal in the eye area to improve humidity around the eye, reduce evaporative tear loss and eliminate any air movement. This may be all that's needed, along with of course an appropriate lubricant.

This is often the most practical route and there are far more choices available, from patches to shields, goggles and masks, whether they have been designed for the purpose or they can be appropriated for the purpose. That's where so many of the issues on my list come into play in the selection and nearly inevitable trial-and-error processes.

CPAP?

Shield/goggle compatibility: One of my must-do-in-2017-if-at-all-possible projects is to come up with a definitive list of compatibility between all the most commonly used CPAP masks and the commonly used night protection products (Onyix/Quartz, Tranquileyes, EyeSeals, and others). I can often, but not always, tell by looking at pictures online what will fit with what but, depending on the exact strap configuration, in many cases it depends on where exactly the straps rest on someone's face.

Clear, opaque, inside, outside? There are so often more complications... is it possible given the strap configuration to put the dry eye shield on last, or must it go on first, and if the latter, is it available in a clear version, and if not, how on earth do you manage? Then there are partner complications: you really need something opaque because your partner keeps the light or TV on forever, but your shield will only fit underneath your mask, meaning if you get up in the night you have to completely disentangle yourself from everything. There is so much to all this! Including things like the...

Rare but notable possibility in stubborn cases: There are documented cases of CPAP-related dry eye problems occurring not from a leaky mask blowing onto the eye surface externally, but rather from a mask on a high setting forcing air up through the nasolacrimal duct onto the eye through the puncta.

Stomach sleeper?

Another of the fairly common problems, but hard to solve in a way that someone can get comfortable sleeping. I'm not going to get into lots of detail here (if you're interested, you might want to glance at the little article I wrote about it for the shop) but I'll just touch on the key principles in play:

Any solution used for stomach sleepers with dry eye needs to take account of the following:

It must be capable of preventing anything from touching the lids or eyes — either stiff enough or vaulting the eyes high enough or both.

It must have a means of securing it in such a way that it can't easily be dislodged.

It needs to be comfortable enough to, you know, sleep.

Recurrent corneal erosions?

RCE has been a big hobby horse of mine for years. An awful lot of people with RCE do not get diagnosed properly until it's gone on a long time. Often they have visited several doctors, sometimes even including multiple corneal specialists, before diagnosis. Even when they do get diagnosed, they don't always get treatment specific to the condition. Recurrent Corneal Erosions are a condition that can happen with, or without, dry eye. (What makes it yet more confusing is that erosions can occur when there is severe dry eye, but that's different from RCE as a disorder.)

If you experience episodes of sharp pains in the middle of the night or first thing in the morning in one or both eyes, accompanied by tearing and blurred vision, please talk to your doctor about it. It can't hurt to ask.

Sunday, July 23, 2017

Today's focus

Today's post is aimed at people who are plagued a lot of the day by really substantial daytime symptoms: burning, grittiness, light sensitivity, and other forms of discomfort.

This post is not about medical treatments at all, though. The assumption is that you're working on addressing medical aspects as best you can. Instead, this is focused on practical measures you can take to manage symptoms in parallel with medical treatments.

What's your pattern?

Some people start out their days in pretty good shape, but their comfort and vision slowly degrade through the day.

For others, symptoms are entirely driven by specific environments and activities; for example, their hard times are at the office, driving, or during computer use, or outdoors in cold weather.

Some people really don't have bad symptoms during the day and can get by with just drops — their real challenge is nights. (I'll be writing about that tomorrow.)

Repeat after me: moisture chambers.

I've been beating this drum for more years than I can remember. The reason I'm such an inveterate fan is that moisture chambers help most people with severe symptoms and really can't cause any harm. There's a lot to like about that combination.

What are moisture chambers? Glasses or sunglasses that have some kind of added or built-in shield (foam, silicone, etc.) closing the gap between the frame and their face.

What's the benefit? (1) Proofing against wind, vents, fans, and moving air in general, which all break up the tear film more quickly; (2) allowing humidity to build up immediately around the eyes; (3) keeping out infiltrates, allergens, etc. The net effect tends to be greater overall comfort with less need for constant lubrication. That's why moisture chambers are a staple for dry eye veterans.

Outdoor use: 7Eye AirShields and WileyX Climate Control are the main contenders. Both brands have many different framestyles available and both sport a removable vented foam eyecup. 7Eye shields tend to be deeper than WileyX. For reference, these brands are $100-200 - you can definitely find much cheaper alternatives with built-in foam, in the $20-50 range. There are additional high end brands like Rudy Project.

Indoors: This is where it gets tricky, because all of the foam-lined moisture chambers like the sports optical types look like goggles if you put clear lenses in them. Ziena Eyewear is really the only brand on the market designed specifically for dry eye and with a view to being reasonably discreet. But you can also get custom moisture chambers made for some conventional glasses — they're just very expensive.

Need Rx? High-end moisture chambers are all Rx-friendly (7Eye, WileyX, Rudy Project, Ziena), though there are limits to how high the prescriptions can go. Some frames take a special high-Rx adaptor.

Over Rx? This is a great way to test the concept before laying out a huge wad of cash on prescription moisture chambers. We have some options at dryeyeshop.com but you can also find them readily on Amazon.

Cost? How long is a piece of string? You can find cheap ones ($20, Walmart, Amazon etc). Non-prescription quality ones run $100 to $200. With prescription lenses, you're looking at more like $300-500, more probably for progressives combined with special coatings.

Humidification?

People living in very dry climates almost certainly need humidifiers at home and work. Some people also use car humidifiers, especially those who drive for a profession, and office workers sometimes use personal humidifiers at their desk.

Are you over-dropping?

Constant dropping: Doctors' opinions will vary, so ask yours. But some people who put in drops more often than every hour or two may find themselves less rather than more comfortable.

Sensitivities: Pay attention to how you are feeling in relation to the time after drops go in. People can develop sensitivities to common polymers in artificial tears and sometimes it never occurs to them that the drops that feel good going in might actually be contributing to discomfort with constant use. Switch things up, get something with a totally different active ingredient if your drops are feeling less comfortable.

Autologous serum: When all commercial artificial tears just seem to make you worse, look into autologous serum, even if only as a way to take a 'drug holiday' for a while from conventional drops.

WHY are you dropping? Many dry eye patients use eyedrops not so much for lubrication as for sensation management. That is, it's not because they're dry, it's because they're uncomfortable or in pain. This is a very important distinction. Those who have severe aqueous deficient dry eye really do have to be very careful to keep lubricated, for the health of their cornea, but those whose primary issues are discomfort rather than dryness per se also have the option to use alternative approaches to comfort... like cold compresses and moisture chambers.

Are you focusing too much on nights?

I come across people sometimes who are putting all of their effort into maxing out moisture overnight, but whose main problems are actually occurring during the day (at least based on what comes out in conversation). Improving moisture during the night is great and will set you up to start the day in better shape, but in terms of setting reasonable expectations, that approach won't necessarily stretch very far into the day. It's important to make sure you're addressing symptoms at the time they're happening.

Cold compresses, chilled drops

Cold compresses are great for corneal pain, and also for inflammation and redness. Incidentally, just because you are doing warm compresses to treat MGD does not mean you can't also use cold compresses for pain management. I remember first hearing about chilled drops back in the early days when Dr Latkany in New York was practically the only one really popularizing the idea of a dry eye specialist. Cold drops were one of his common tips that many people picked up on.

How about a mid-day re-boot?

For those whose symptoms progress steadily downhill throughout the day, a half-hour break to baby them somewhere along the way can be very helpful.

15-30 minutes of shut-eye with a cold wet compress — anything from a wet cloth over a gelpack to the luxurious Tranquileyes XL Advanced kits — can do the trick.

PROSE, Sclerals

People who cannot get comfortable or functional at all during the day, even with maxed-out medical treatment and moisture chamber glasses, are probably going to want to investigate PROSE/sclerals.

Saturday, July 22, 2017

It's Saturday! This post will be yet shorter and sweeter than the last, and then I'm headed to the movies with my daughter!

Local support groups

There are, unfortunately, very, very few local support groups specifically for dry eye. The only long-term group that I know of, in fact, is the wonderful Orange County Dry Eye Support Group in the LA area. I am hoping that, somewhere in the 2017-2018 timeframe, I'll be able to move forward with my longtime dream to be part of organizing a national network of dry eye support groups.

Meantime, the best resource for local groups is the Sjogrens Syndrome Foundation. (Obviously, many, probably most of you don't have Sjogrens, but their groups are the closest thing there is, since most people with Sjogrens Syndrome have dry eye.)

The SSF local support groups they have are treasure troves of practical information on who the best local dry eye doctors are, and which doctors are attuned to the needs of specific disease groups (Sjogrens, obviously, but others too), and doctors who are equipped for specialty treatments such as autologous serum drops, Lipiflow, etc.

But just the ability to meet up, in person, with other people who understand your situation and may have practical pointers about coping and daily management, is huge.

Validation! Immediate connections with people who get it. This is really important.

Support! Kind voices that will not minimize your experience.

Practical tips! A great deal of the lifestyle management information you need and which cannot be had anywhere else.

Information! Tons of quite good information on diagnosis, treatment and management that, again, you may not be able to get anywhere else.

The CURSES of social media include:

An over-abundance of dry eye paraphernalia-peddling predators (ooooh, that was a really fun term to coin!). They come in many guises, including doctors and patients. They usually come bearing supplements. They exploit the vulnerable.

The illusion of understanding trends, especially treatment failures. Hearing similar voices and reading similar experiences online often gives you a completely unrealistic pseudo-insight into what's normal. It's all too easy to think a certain treatment "doesn't work" just because 15 people have dissed it on Facebook in the last 36 hours. One must always bear in mind that only people with a problem post in these forums... all the ones that got better and went away, or at any rate had a successful treatment course, are invisible. You cannot get anything but a heavily skewed perspective on macro trends in a Facebook group.

Unhealthy addiction and way too much screen time, which is a bad thing when you have dry eye.

All kinds of really, really, really bad ideas about the 'natural' things you should put in your eyes that are "safer" than drugs. I don't like drugs either, but-but-but be reasonable, people :)

It's the weekend, and I'm a day late anyway, so I'm going to keep this short and sweet! Well, relatively.

A couple of "oldies but goodies"....

Many years ago I wrote a couple of lengthy articles about dry eye medical care, particularly as regards navigating dry-eye specific pitfalls of the doctor-patient relationship. There have been a lot of changes in the dry eye world since then, but there is still a great deal in those articles that's directly relevant to patient needs today, so I decided to post the links here.

Navigating current trends

Things are changing all the time. Treatments that hardly anyone even knew about ten years ago are being kicked around online frequently and while they definitely aren't all being scouted in non-specialist eye care practices, awareness is clearly on the rise. Demographics are also putting heavy pressure on eye care practitioners to bone up on the latest and greatest dry eye tools.

Each change brings its own issues along for the ride, of course. I'm going to highlight here random current issues to supplement the previous articles.

The "Dry Eye Specialist" phenomenon and how to beat it

In the aftermath of the 2008 recession, which drained Americans' discretionary income for things like LASIK, a curious trend followed. Clinics that primarily advertised as laser surgery centers in the past gradually began hanging out a new shingle. The wording varied, but the bottom line was they were starting to tout themselves as a the local go-to dry eye clinic. This trend continued and picked up speed in ensuing years, fueled by things like demographics, Lipiflow emerging as a much-needed replacement cash cow, and increasingly demanding consumers who are suffering enough to not settle for the "Ye Olde Schirmer, Plug-n-Drop, oh, and Restasis too because we might as well" school of dry eye diagnosis and treatment.

Unfortunately a lot of these new self-described dry eye specialists and dry eye clinics really don't offer much more than increased advertising. Step right up, folks, get your Xiidra script here!

Would the real dry eye specialists please stand up?

Technically, there's no such thing (it's not a formal subspecialty as far as I know), so anyone can label themselves a specialist. Trying to find a truly helpful doctor is extremely challenging unless you already know the dry eye landscape and its craters quite well AND are social media savvy.

My rules of thumb have always been that many people can benefit from a really smart optometrist on their team for regular visits, because optometrists by and large are more accessible and will spend more time with you than most ophthalmologists. But you also want a good cornea specialist ophthalmologist with a specific professional/scientific (as opposed to financial) emphasis on dry eye, particularly when you're in the worst stages and/or don't yet have a really super-thorough and accurate diagnosis, and also if you have special medical needs.

Finding the right kind of optometrist is all about hunting on social media, unless you're lucky enough to have access to the pooled knowledge of a good local support group. Finding a cornea specialist ophthalmologist? Scour the resumes. The problem with cornea specialists is that a significant majority aren't actually interested in corneal disease. They're interested in corneal surgery, probably refractive (take a bow, LASIK industry, you have transformed the profession). The ophthalmologist gem you are looking for is a cornea specialist that really digs disease, as opposed to just snatching at and sporting the dry eye diagnostics and treatments du jour as announced from a podium somewhere.

The "Micro-Manage Your Doctor" trend

So here's another thing I'm seeing more of these days. The hyper-educated patient who goes to their doctor with a lengthy shopping list of (a) tests they want done, (b) potential diagnoses they want to discuss, and (c) potential treatment options they want full-on support for, including but not limited to drugs (manufactured and compounded), devices, surgeries, consumer products, dietary plans and oh yes a long litany of dietary supplements.

I am absolutely all for educated patients and partnering with our doctors.

Thursday, July 20, 2017

Yesterday's tips were focused on recognizing dry eye symptoms for what they are (or might be), and getting ahead of them with some purely practical prevention pointers. Today, we're going to shift to prevention tips for navigating some medical stuff.

Don't hurt yourself through ignorance...

...about drops, drugs, devices and surgeries.

The fact is, a great many medical treatments, drugs (ocular and systemic), and surgeries involving the eyes and lids CAUSE dry eyes - sometimes mild, sometimes temporary, but also sometimes severe and sometimes chronic or permanent. Getting dry eye at all, in any form, is lousy. Getting a really nasty, persistent, life-altering form of dry eye and knowing it was preventable is truly the pits.

There are far too many forms of medically-induced dry eye (also called 'iatrogenic' dry eye) for me to cover here, so I'm just going to hit on a FEW frequent offenders that should be emphasized. Iatrogenic dry eye is actually such a big topic that the international medical consensus project known as TFOS DEWS II, whose 10-year report is about to be published, had an entire subcommittee and massive chapter focus just on this!

OTC Drop Shopping Tips

Look for eye drops with these things on the label:

Preservative-Free. Almost anything preservative-free, by the way, will come in a box of 30 or more individual vials. Waste of plastic? Sure. On the other hand, preservatives (i.e. what makes it possible to put eyedrops in a bottle) are toxic to the cornea. So pick your poison.

Lubricant Eye Drop (or geldrop).

Alternatively, homeopathic drops. For mild dry eye or ocular allergy symptoms, they can be helpful without posing the types of risks medicated drops may introduce.

Try to avoid purchasing any of the following eye drops for regular use:

Redness relievers (vasoconstrictors). These are doubly damaging to the cornea. First, they have a rebound redness factor when used repeatedly, and second, they are usually preserved with benzalkonium chloride, which is quite toxic to the cornea. If you must use redness relievers, do so infrequently — save them for special occasions. *BUYER BEWARE*: There are many 'combo' drops on the market these days, and they get terribly confusing because they also claim to be lubricants. Just don't buy things with a redness reliever ingredient.

Antihistamine (allergy) drops, except for brief use, or unless you're seeing an eye doctor, in which case they'll probably want to put you on a better, prescription allergy drop anyway. That's *if* you really do have ocular allergies — because maybe your eyes are itchy due to dryness, after all! But as I was saying, antihistamine drops are drying, and again, have toxic preservatives. That's true of both OTC and Rx allergy drops. If you've got to use one, use the one that works the best.

Eyewashes and salines, except for your first aid kit. Look out for preservatives. Don't overuse anything like this - they may be wet, but they have no lubricating properties and they dilute your precious tear film, which you can't do too terribly often without paying for it.

Rx Drop Awareness Tips

TOP TIP: Avoid using anything preserved on a daily basis for longer than a month if possible. If you have to, talk to your doctor about the preservative side effects and if it's possible to get a preservative-free version.

Glaucoma drops, historically, are top offenders. They have to be taken daily, and daily exposure to the most toxic preservatives can be a big dry eye contributor. There are many preservative-free glaucoma drops now, and ones with milder preservatives. Make sure you have the preservative talk with your glaucoma doctor.

Steroid drops and antibiotic drops are two more commonly used classes of eyedrops that are usually preserved with the most toxic preservative (benzalkonium chloride). If you don't need to be on them long, you will probably not want to bother worrying about it, but if for any reason you need to stay on them longer than a conventional course lasts, talk to your doctor about preservative side effect concerns, including dryness.

Drug Awareness Facts

Oodles and gazoodles of drugs are, or at any rate may be, drying. So it gets tricky talking about them ("Fine, but now that I know that, what do I do?"). With drugs in general, there is no free lunch, and it's all about navigating the tradeoffs. But the aspect I would want to emphasize is that IF you know you are at dry eye risk for other reasons, AND the drug you need to take is on the dry eye-causing spectrum, it's worth a conversation with the prescribing doctor about your concerns, drug selection and alternatives, and dosage. For example, there are a ton of antidepressants on the market, and while not all of them may be appropriate for you, you can at least raise the dry eye side effect potential with your doctor and ask them for help to pin down those suitable for you that are less frequently associated with dry eye.

Top dry eye offender drug categories (in random order):

Antihistamines

Nasal decongestants

Blood pressure medications (beta blockers, diuretics)

Antidepressants

Antipsychotics

Parkinsons drugs

Hormone therapy; oral contraceptives

Acne medications

Sleeping pills

Pain relievers

Device hangup: CPAP and APAP

At the Dry Eye Shop we talk constantly with people whose eyes are dried out by their CPAP masks — they call, often after referral by their doctor, to get advice on shields, masks, or patches they could use to protect their eyes. CPAP is in such common usage, and has been for so long, that it is absolutely staggering to me how many people still struggle for a long time with this before someone finally tells them there are solutions and even products made specifically to help with it.

It would be nice if everyone could get a CPAP mask that fit perfectly and didn't leak, but till then, physical protection for the eyes, even if only a strip of plastic wrap, is very important for many CPAP users.

Surgery hangup #1: LASIK, et cetera

July 20th, 2017 - today! - is my 16th 'laserversary'... a term many of us who experienced laser surgery complications in the old days coined for a memorable day that we don't exactly celebrate. As you might imagine, I'm not a terribly big fan. No regrets about my own experience, because it ended up determining a new course for my life that gives me a great deal of fulfillment every day, but because it came at a high cost to vision and comfort, I would never recommend it for someone else.

Among the many things on the scale stacked up against LASIK, the dry eye risk features prominently, and all the more so because no one who gets LASIK has any idea how bad post LASIK dry eye can be when it's bad.

Top illusions to avoid suckering to:

That you can escape this risk by going to the best, most reputable surgeon in your area. (Naw. We all did that too.)

That technology has improved so much this doesn't happen anymore.

That dry eye treatments are so good it doesn't matter.

That if you already have dry eye, a little increase doesn't matter. (Actually, it might mean the difference between dry eye and DRY EYE.)

That the worst that could happen is you need eyedrops or Restasis or Xiidra or plugs.

That your surgeon will be will equipped to help you through any ensuing dryness. (LASIK surgeons and dry eye specialists just don't normally come under the same label.)

Surgery hangup #2: Elective eyelid surgeries (blepharoplasty)

There is a particularly painful version of dry eye that comes sometimes with blepharoplasty - specifically, when the lids come up too short.

Top tips for lowering risk:

Seek only an oculoplastic surgeon, NEVER a plastic surgeon, no matter how qualified! Oculoplastic surgeons are ophthalmologists who do surgery on the eyelids. General plastic surgeons don't have enough specialized knowledge of the tear system.

Get a complete, detailed dry eye workup with a specialist before a blepharoplasty, to see if you have any pre-existing dry eye or dry eye risk factors that could make you unusually vulnerable to dry eye side effects.